Provider First Line Business Practice Location Address:
5310 RISING SUN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19120-3031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-455-6878
Provider Business Practice Location Address Fax Number:
215-455-8560
Provider Enumeration Date:
10/04/2006